<h:html xmlns:h="http://www.w3.org/1999/xhtml" xmlns:xsd="http://www.w3.org/2001/XMLSchema" xmlns="http://www.w3.org/2002/xforms">
  <h:head>
    <h:title>CRS Rapid Assessment</h:title>
    <model> 
      <instance>
        <CRSForm> 
          <general>
            <dis-type />
            <gram-p />
            <block />
            <district />
            <num-hh />
            <total-fam />
            <aff-house />
            <missing />
            <deaths />
          </general>
        
          <demographic>
            <female>
              <under-5 />
              <age-5-14 />
              <age-15-59 />
              <over-60 />
              <pregnant />
              <unaccompanied />
              <challenged />
              <hiv />
              <vulnerable />
            </female>
            <male>
              <under-5 />
              <age-5-14 />
              <age-15-59 />
              <over-60 />
              <unaccompanied />
              <challenged />
              <hiv />
              <vulnerable />
            </male>
          </demographic>
          
          <health>
            <access />
            <debris />
            <healthserv />
            <morbidity>
              <injuries />
              <diarrheal />
              <measles />
              <malnutrition />
              <dehydration />
              <respiratory />
              <malaria />
              <exposure />
              <other />
            </morbidity>
          </health>  
          
          <infrastructure>
            <services>
              <school />
              <office />
              <phc />
            </services>
            <available />
            <warehouses />
            <vehicles />
            <boats />
          </infrastructure>    
      
          <shelter>
            <not-safe />
            <demarcated />
            <fully-damaged />
            <partially-damaged />
            <destroyed />
            <host-families />
            <emergency />
            <temporary />
            <left />
            <lost>
              <cooking />
              <clothes />
              <cloths />
              <bedsheets />
              <water />
              <soap />
            </lost>
          </shelter>
          
          <wat-san>
            <access />
            <collect />
            <other-uses />
            <treating />
            <treatment />
            <toilets-present />
            <t-cond-good />
            <t-cond-bad />
            <drainage-cond />
            <designated-def />
            <def-away />
          </wat-san>
          
          <food>
            <food />
            <fuel />
            <fodder />
          </food>
          
          <response>
            <local>
		      <food>
                <people />
		        <days />
		      </food>
		      <water>
		        <people />
                <days />
	          </water>
              <treatment>
	            <people />
	            <days />
	          </treatment>
   	          <shelter>
	            <people />
		        <days />
		      </shelter>
		      <cloth>
		        <people />
                <days />
	          </cloth>
	          <fodder>
	            <people />
	            <days />
              </fodder>
            </local>
            <ngo>
		      <food>
                <people />
		        <days />
		      </food>
		      <water>
		        <people />
                <days />
	          </water>
              <treatment>
	            <people />
	            <days />
	          </treatment>
   	          <shelter>
	            <people />
		        <days />
		      </shelter>
		      <cloth>
		        <people />
                <days />
	          </cloth>
	          <fodder>
	            <people />
	            <days />
              </fodder>
            </ngo>   
          </response>
          
          <protection>
            <danger />
            <places-safe />
            <school />
          </protection>
          
          <livelihoods />
          
        </CRSForm>                 
      </instance>
      
      <bind id="a" nodeset="/CRSForm/general/dis-type" type="xsd:int" />
      <bind id="b" nodeset="/CRSForm/general/gram-p" type="xsd:int" />
      <bind id="c" nodeset="/CRSForm/general/block" type="xsd:int" />
      <bind id="d" nodeset="/CRSForm/general/district" type="xsd:int" />
      <bind id="e" nodeset="/CRSForm/general/num-hh" type="xsd:int" />
      <bind id="f" nodeset="/CRSForm/general/total-fam" type="xsd:int" />
      <bind id="g" nodeset="/CRSForm/general/aff-house" type="xsd:int" />
      <bind id="h" nodeset="/CRSForm/general/missing" type="xsd:int" />
      <bind id="i" nodeset="/CRSForm/general/deaths" type="xsd:int" />
      <bind id="j" nodeset="/CRSForm/demographic/female/under-5" type="xsd:int" />
      <bind id="k" nodeset="/CRSForm/demographic/female/age-5-14" type="xsd:int" />
      <bind id="l" nodeset="/CRSForm/demographic/female/age-15-59" type="xsd:int" />
      <bind id="m" nodeset="/CRSForm/demographic/female/over-60" type="xsd:int" />
      <bind id="n" nodeset="/CRSForm/demographic/female/pregnant" type="xsd:int" />
      <bind id="o" nodeset="/CRSForm/demographic/female/unaccompanied" type="xsd:int" />
      <bind id="p" nodeset="/CRSForm/demographic/female/challenged" type="xsd:int" />
      <bind id="q" nodeset="/CRSForm/demographic/female/hiv" type="xsd:int" />
      <bind id="r" nodeset="/CRSForm/demographic/female/vulnerable" type="xsd:int" />
      <bind id="s" nodeset="/CRSForm/demographic/male/under-5" type="xsd:int" />
      <bind id="t" nodeset="/CRSForm/demographic/male/age-5-14" type="xsd:int" />
      <bind id="u" nodeset="/CRSForm/demographic/male/age-15-59" type="xsd:int" />
      <bind id="v" nodeset="/CRSForm/demographic/male/over-60" type="xsd:int" />
      <bind id="w" nodeset="/CRSForm/demographic/male/unaccompanied" type="xsd:int" />
      <bind id="x" nodeset="/CRSForm/demographic/male/challenged" type="xsd:int" />
      <bind id="y" nodeset="/CRSForm/demographic/male/hiv" type="xsd:int" />
      <bind id="z" nodeset="/CRSForm/demographic/male/vulnerable" type="xsd:int" />
      <bind id="h1" nodeset ="/CRSForm/health/access" type="xsd:int" />
      <bind id="h2" nodeset ="/CRSForm/health/debris" type="xsd:int" />
      <bind id="h3" nodeset ="/CRSForm/health/healthserv" type="xsd:string" />
      <bind id="h4" nodeset ="/CRSForm/health/morbidity/injuries" type="xsd:int" />
      <bind id="h5" nodeset ="/CRSForm/health/morbidity/diarrheal" type="xsd:int" />
      <bind id="h6" nodeset ="/CRSForm/health/morbidity/measles" type="xsd:int" />
      <bind id="h7" nodeset ="/CRSForm/health/morbidity/malnutrition" type="xsd:int" />
      <bind id="h8" nodeset ="/CRSForm/health/morbidity/dehydration" type="xsd:int" />
      <bind id="h9" nodeset ="/CRSForm/health/morbidity/respiratory" type="xsd:int" />
      <bind id="ha" nodeset ="/CRSForm/health/morbidity/malaria" type="xsd:int" />
      <bind id="hb" nodeset ="/CRSForm/health/morbidity/exposure" type="xsd:int" />
      <bind id="hc" nodeset ="/CRSForm/health/morbidity/other" type="xsd:int" />
      <bind id="i1" nodeset ="/CRSForm/infrastructure/services/school" type="xsd:string" />
      <bind id="i2" nodeset ="/CRSForm/infrastructure/services/office" type="xsd:string" />
      <bind id="i3" nodeset ="/CRSForm/infrastructure/services/phc" type="xsd:string" />
      <bind id="i4" nodeset ="/CRSForm/infrastructure/available" type="xsd:string" />
      <bind id="i5" nodeset ="/CRSForm/infrastructure/warehouses" type="xsd:int" />
      <bind id="i6" nodeset ="/CRSForm/infrastructure/vehicles" type="xsd:int" />
      <bind id="i7" nodeset ="/CRSForm/infrastructure/boats" type="xsd:int" />
      <bind id="s1" nodeset ="/CRSForm/shelter/not-safe" type="xsd:int" />
      <bind id="s2" nodeset ="/CRSForm/shelter/demarcated" type="xsd:string" />
      <bind id="s3" nodeset ="/CRSForm/shelter/fully-damaged" type="xsd:int" />
      <bind id="s4" nodeset ="/CRSForm/shelter/partially-damaged" type="xsd:int" />
      <bind id="s5" nodeset ="/CRSForm/shelter/destroyed" type="xsd:int" />
      <bind id="s6" nodeset ="/CRSForm/shelter/host-families" type="xsd:int" />
      <bind id="s7" nodeset ="/CRSForm/shelter/emergency" type="xsd:int" />
      <bind id="s8" nodeset ="/CRSForm/shelter/temporary" type="xsd:int" />
      <bind id="s9" nodeset ="/CRSForm/shelter/left" type="xsd:int" />
      <bind id="sa" nodeset ="/CRSForm/shelter/lost/cooking" type="xsd:int" />
      <bind id="sb" nodeset ="/CRSForm/shelter/lost/clothes" type="xsd:int" />
      <bind id="sc" nodeset ="/CRSForm/shelter/lost/cloths" type="xsd:int" />
      <bind id="sd" nodeset ="/CRSForm/shelter/lost/bedsheets" type="xsd:int" />
      <bind id="se" nodeset ="/CRSForm/shelter/lost/water" type="xsd:int" />
      <bind id="sf" nodeset ="/CRSForm/shelter/lost/soap" type="xsd:int" />
      <bind id="w0" nodeset ="/CRSForm/wat-san/access" type="xsd:int" />
      <bind id="w1" nodeset ="/CRSForm/wat-san/collect" type="xsd:string" />
      <bind id="w2" nodeset ="/CRSForm/wat-san/other-uses" type="xsd:int" />
      <bind id="w3" nodeset ="/CRSForm/wat-san/treating" type="xsd:string" />
      <bind id="w4" nodeset ="/CRSForm/wat-san/treatment" type="xsd:string" />
      <bind id="w5" nodeset ="/CRSForm/wat-san/toilets-present" type="xsd:string" />
      <bind id="w6" nodeset ="/CRSForm/wat-san/t-cond-good" type="xsd:int" />
      <bind id="w7" nodeset ="/CRSForm/wat-san/t-cond-bad" type="xsd:int" />
      <bind id="w8" nodeset ="/CRSForm/wat-san/drainage-cond" type="xsd:string" />
      <bind id="w9" nodeset ="/CRSForm/wat-san/designated-def" type="xsd:string" />
      <bind id="wa" nodeset ="/CRSForm/wat-san/def-away" type="xsd:string" />
      <bind id="f1" nodeset ="/CRSForm/food/food" type="xsd:int" />
      <bind id="f2" nodeset ="/CRSForm/food/fuel" type="xsd:int" />
      <bind id="f3" nodeset ="/CRSForm/food/fodder" type="xsd:int" />
      <bind id="r1" nodeset ="/CRSForm/response/local/food/people" type="xsd:int" />
      <bind id="r2" nodeset ="/CRSForm/response/local/food/days" type="xsd:int" />
      <bind id="r3" nodeset ="/CRSForm/response/local/water/people" type="xsd:int" />
      <bind id="r4" nodeset ="/CRSForm/response/local/water/days" type="xsd:int" />
      <bind id="r5" nodeset ="/CRSForm/response/local/treatment/people" type="xsd:int" />
      <bind id="r6" nodeset ="/CRSForm/response/local/treatment/days" type="xsd:int" />
      <bind id="r7" nodeset ="/CRSForm/response/local/shelter/people" type="xsd:int" />
      <bind id="r8" nodeset ="/CRSForm/response/local/shelter/days" type="xsd:int" />
      <bind id="r9" nodeset ="/CRSForm/response/local/cloth/people" type="xsd:int" />
      <bind id="ra" nodeset ="/CRSForm/response/local/cloth/days" type="xsd:int" />
      <bind id="rb" nodeset ="/CRSForm/response/local/fodder/people" type="xsd:int" />
      <bind id="rc" nodeset ="/CRSForm/response/local/fodder/days" type="xsd:int" />
      <bind id="rd" nodeset ="/CRSForm/response/ngo/food/people" type="xsd:int" />
      <bind id="re" nodeset ="/CRSForm/response/ngo/food/days" type="xsd:int" />
      <bind id="rf" nodeset ="/CRSForm/response/ngo/water/people" type="xsd:int" />
      <bind id="rg" nodeset ="/CRSForm/response/ngo/water/days" type="xsd:int" />
      <bind id="rh" nodeset ="/CRSForm/response/ngo/treatment/people" type="xsd:int" />
      <bind id="ri" nodeset ="/CRSForm/response/ngo/treatment/days" type="xsd:int" />
      <bind id="rj" nodeset ="/CRSForm/response/ngo/shelter/people" type="xsd:int" />
      <bind id="rk" nodeset ="/CRSForm/response/ngo/shelter/days" type="xsd:int" />
      <bind id="rl" nodeset ="/CRSForm/response/ngo/cloth/people" type="xsd:int" />
      <bind id="rm" nodeset ="/CRSForm/response/ngo/cloth/days" type="xsd:int" />
      <bind id="rn" nodeset ="/CRSForm/response/ngo/fodder/people" type="xsd:int" />
      <bind id="ro" nodeset ="/CRSForm/response/ngo/fodder/days" type="xsd:int" />
      <bind id="p1" nodeset ="/CRSForm/protection/danger" type="xsd:string" />
      <bind id="p2" nodeset ="/CRSForm/protection/places-safe" type="xsd:string" />
      <bind id="p3" nodeset ="/CRSForm/protection/school" type="xsd:int" />
	  <bind id="x1" nodeset ="/CRSForm/livelihoods" type="xsd:int" />
    </model>
  </h:head>    
  <h:body>
  
    <group>
    <label>General Assessment</label>
    <hint>Answer the following questions on general assessment</hint>
    <select1 bind="a">
      <label>Type of Disaster</label>
      <item>
        <label>Flood</label>
        <value>1</value>
      </item>
      <item>
        <label>Cyclone</label>
        <value>2</value>
      </item>
      <item>
        <label>Earthquake</label>
        <value>3</value>
      </item>
      <item>
        <label>Landslide</label>
        <value>4</value>
      </item>
      <item>
        <label>Industrial/Chemical</label>
        <value>5</value>
      </item>
      <item>
        <label>Tsunami</label>
        <value>6</value>
      </item>
      <item>
        <label>Fire</label>
        <value>7</value>
      </item>
      <item>
        <label>Draught</label>
        <value>8</value>
      </item>
    </select1>  
    
    <select1 bind="b">
      <label>Gram Panchayat</label>
      <item>
        <label>Gram Panchayat A</label>
        <value>1</value>
      </item>
      <item>
        <label>Gram Panchayat B</label>
        <value>2</value>
      </item>
      <item>
        <label>Gram Panchayat C</label>
        <value>3</value>
      </item>
      <item>
        <label>Gram Panchayat D</label>
        <value>4</value>
      </item>
      <item>
        <label>Gram Panchayat E</label>
        <value>5</value>
      </item>
      <item>
        <label>Gram Panchayat F</label>
        <value>6</value>
      </item>
    </select1>   
    
    <select1 bind="c">
      <label>Block</label>
      <item>
        <label>Block A</label>
        <value>1</value>
      </item>
      <item>
        <label>Block B</label>
        <value>2</value>
      </item>
      <item>
        <label>Block C</label>
        <value>3</value>
      </item>
      <item>
        <label>Block D</label>
        <value>4</value>
      </item>
      <item>
        <label>Block E</label>
        <value>5</value>
      </item>
      <item>
        <label>Block F</label>
        <value>6</value>
      </item>
    </select1>        
     
    <select1 bind="d">
      <label>District</label>
      <item>
        <label>District A</label>
        <value>1</value>
      </item>
      <item>
        <label>District B</label>
        <value>2</value>
      </item>
      <item>
        <label>District C</label>
        <value>3</value>
      </item>
      <item>
        <label>District D</label>
        <value>4</value>
      </item>
      <item>
        <label>District E</label>
        <value>5</value>
      </item>
      <item>
        <label>District F</label>
        <value>6</value>
      </item>
    </select1>
      
    <input bind="e">
      <label>Individuals/Household</label>
    </input>
    
    <input bind="f">
      <label>Total Families Affected</label>
    </input>
    
    <input bind="g">
      <label>Affected Households</label>
    </input>            

    <input bind="h">
      <label>People Missing</label>
    </input>
    
    <input bind="i">
      <label>Number of Deaths</label>
    </input>
    </group>
 
    <group>
    <label>Females Affected</label> 
    <input bind="j">
      <label>Under 5 yrs</label>
    </input>

    <input bind="k">
      <label>5-14 yrs</label>
    </input>
    
    <input bind="l">
      <label>15-59 yrs</label>
    </input>
    
    <input bind="m">
      <label>60+ yrs</label>
    </input>
    
    <input bind="n">
      <label>Pregnant/Lactating</label>
    </input>
    
    <input bind="o">
      <label>Unaccompanied Elders</label>
    </input>
    
    <input bind="p">
      <label>Physically/Mentally Challenged</label>
    </input>
    
    <input bind="q">
      <label>HIV Affected/Infected</label>
    </input>
    
    <input bind="r">
      <label>Socially Vulnerable Groups</label>
    </input>
    </group>
    
    <group>
    <label>Males Affected</label> 
    <input bind="s">
      <label>Under 5 yrs</label>
    </input>

    <input bind="t">
      <label>5-14 yrs</label>
    </input>
    
    <input bind="u">
      <label>15-59 yrs</label>
    </input>
    
    <input bind="v">
      <label>60+ yrs</label>
    </input>
    
    <input bind="w">
      <label>Unaccompanied Elders</label>
    </input>
    
    <input bind="x">
      <label>Physically/Mentally Challenged</label>
    </input>
    
    <input bind="y">
      <label>HIV Affected/Infected</label>
    </input>
    
    <input bind="z">
      <label>Socially Vulnerable Groups</label>
    </input>
    </group>
    
    <group>
    <label>Health</label>

    <input bind="h1">
      <label>How many people do not have access to health services?</label>
    </input>
    
    <select1 bind="h2">
      <label>Are dead bodies (humans and animal) and debris being removed?</label>
      <item>
        <label>Yes</label>
        <value>y</value>
      </item>
      <item>
        <label>No</label>
        <value>n</value>
      </item>
    </select1>
    
    <select bind="h3">
      <label>Which causes of morbidity have access to health services?</label>
      <item>
        <label>Injuries</label>
        <value>"y"</value>
      </item>
      <item>
        <label>Diarrheal Disease</label>
        <value>"y"</value>
      </item>
      <item>
        <label>Measles</label>
        <value>"y"</value>
      </item>
      <item>
        <label>Malnutrition</label>
        <value>"y"</value>
      </item>
      <item>
        <label>Dehydration</label>
        <value>"y"</value>
      </item>
      <item>
        <label>Acute Respiratory Infections</label>
        <value>"y"</value>
      </item>
      <item>
        <label>Malaria</label>
        <value>"y"</value>
      </item>
      <item>
        <label>Exposure</label>
        <value>"y"</value>
      </item>
      <item>
        <label>Other</label>
        <value>"y"</value>
      </item>
    </select>
    </group>
    
    <group>
    <label>Infrastructure</label>
      <group>
      <label>What services were damaged?</label>
      <select1 bind="i1">
        <label>School</label>
        <item>
          <label>Fully Damaged</label>
          <value>"F"</value>
        </item>
        <item>
          <label>Partially Damaged</label>
          <value>"P"</value>
        </item> 
        <item>
          <label>No Damage</label>
          <value>"N"</value>
        </item>
      </select1>
      
      <select1 bind="i2">
        <label>Panchayat Office</label>
        <item>
          <label>Fully Damaged</label>
          <value>"F"</value>
        </item>
        <item>
          <label>Partially Damaged</label>
          <value>"P"</value>
        </item> 
        <item>
          <label>No Damage</label>
          <value>"N"</value>
        </item>
      </select1>
      
      <select1 bind="i3">
        <label>PHC</label>
        <item>
          <label>Fully Damaged</label>
          <value>"F"</value>
        </item>
        <item>
          <label>Partially Damaged</label>
          <value>"P"</value>
        </item> 
        <item>
          <label>No Damage</label>
          <value>"N"</value>
        </item>
      </select1> 
      </group>
      
      <select bind="i4">
        <label>Are the following available?</label>
        <item>
          <label>Road out of the affected area for victims</label>
          <value>"y"</value>
        </item>
        <item>
          <label>Road into the affected area for aid</label>
          <value>"y"</value>
        </item>
        <item>
          <label>Electricity/Power Supply</label>
          <value>"y"</value>
        </item>
        <item>
          <label>Telecommunications Systems</label>
          <value>"y"</value>
        </item>
        <item>
          <label>PDS</label>
          <value>"y"</value>
        </item>
        <item>
          <label>Adequate Emergency Shelter</label>
          <value>"y"</value>
        </item>
        <item>
          <label>Space for control room</label>
          <value>"y"</value>
        </item>
        <item>
          <label>Local partner network</label>
          <value>"y"</value>
        </item>
        <item>
          <label>Means to manage relief stock</label>
          <value>"y"</value>
        </item>
        <item>
          <label>Distribution place and volunteers</label>
          <value>"y"</value>
        </item>
      </select>
      
      <input bind="i5">
        <label>How many warehouses exist?</label>
      </input>
      
      <input bind="i6">
        <label>How many vehicles are available?</label>
      </input>
      
      <input bind="i7">
        <label>How many boats are available?</label>
      </input>       

    </group>
    
    <group>
      <label>Shelter/NFI</label>
      
      <input bind="s1">
        <label>How many people are not in safe shelters?</label>
      </input>
      
      <select1 bind="s2">
        <label>Is a demarcated site for relief available?</label>
        <item>
          <label>Yes</label>
          <value>"y"</value>
        </item>
        <item>
          <label>No</label>
          <value>"n"</value>
        </item>
      </select1>
      
      <input bind="s3">
        <label># of houses fully damaged</label>
      </input>
      
      <input bind="s4">
        <label># of houses partially damaged</label>
      </input>
      
      <input bind="s5">
        <label># of families living in damaged or destroyed shelter</label>
      </input>
      
      <input bind="s6">
        <label># of families displaced and living with host families</label>
      </input>
      
      <input bind="s7">
        <label># of families living in existing emergency shelters</label>
      </input>
      
      <input bind="s8">
        <label># of families living in temporary shelters or relief camps</label>
      </input>
      
      <input bind="s9">
        <label># of families who have left the affected village</label>
      </input>
	  
	  <group>
	    <label># of families who have lost the following household items:</label>
	    <input bind="sa">
	      <label>Cooking Utensils</label>
	    </input>
	    <input bind="sb">
	      <label>Clothes</label>
	    </input>
	    <input bind="sc">
	      <label>Cloths</label>
	    </input>
	    <input bind="sd">
	      <label>Bed Sheets</label>
	    </input>
	    <input bind="se">
	      <label>Water Storage Containers</label>
	    </input>
	    <input bind="sf">
	      <label>Washing Soap</label>
	    </input>
	  </group>
	</group>
	
	<group>
	  <label>Water/Sanitation</label>
	  
	  <input bind="w0">
	    <label>How many families lack access to drinking water?</label>
	  </input>
	  
	  <select bind="w1">
	    <label>From where does the community normally collect drinking water? (Indicate which are submerged)</label>
	    <item>
	      <label>River</label><value>"y"</value>
	    </item>
	    <item>
	      <label>Tube Wells</label><value>"y"</value>
	    </item>
	    <item>
	      <label>Wells</label><value>"y"</value>
	    </item>
	    <item>
	      <label>Ponds</label><value>"y"</value>
	    </item>
	  </select>
	  
	  <input bind="w2">
	    <label>How many families do not have water for other uses (i.e. cooking, washing, bathing)?</label>
	  </input>
	  
	  <select1 bind="w3">
        <label>Are families treating their cooking and drinking water?</label>
        <item>
          <label>Yes</label><value>"y"</value>
        </item>
        <item>
          <label>No</label><value>"n"</value>
        </item>
      </select1>
      
      <select1 bind="w4">
        <label>How are they treating water?</label>
        <item>
          <label>Boiling</label><value>"a"</value>
        </item>
        <item>
          <label>Halogen Tablets</label><value>"b"</value>
        </item>
        <item>
          <label>Water Filter</label><value>"b"</value>
        </item>
        <item>
          <label>Filtration with cloth</label><value>"b"</value>
        </item>
        <item>
          <label>Only Sedimentation</label><value>"b"</value>
        </item>
      </select1>
      
      <select1 bind="w5">
        <label>Are there toilets?</label>
        <item>
          <label>Yes</label><value>"y"</value>
        </item>
        <item>
          <label>No</label><value>"n"</value>
        </item>
      </select1>
      
      <group>
        <label>Condition of toilets</label>
        <input bind="w6"><label>Good</label></input>
        <input bind="w7"><label>Poor but usable</label></input>
      </group>
      
      <select1 bind="w8">
        <label>Condition of Drainage</label>
        <item>
          <label>Good</label><value>"a"</value>
        </item>
        <item>
          <label>Poor</label><value>"b"</value>
        </item>
      </select1>
        
	  <select1 bind="w9">
        <label>Are there designated places for defecation?</label>
        <item>
          <label>Yes</label><value>"y"</value>
        </item>
        <item>
          <label>No</label><value>"n"</value>
        </item>
      </select1>
	  
	  <select1 bind="wa">
        <label>Are the defecation areas away from water sources or bathing areas?</label>
        <item>
          <label>Yes</label><value>"y"</value>
        </item>
        <item>
          <label>No</label><value>"n"</value>
        </item>
      </select1>
    </group>
    
    <group>
      <label>Food</label>
      <input bind="f1">
	    <label>How many families do not have enough food for 2 weeks?</label>
	  </input>
	  <input bind="f2">
	    <label>How many families do not have enough cooking fuel for 2 weeks?</label>
	  </input>
	  <input bind="f3">
	    <label>How many livestock do not have fodder for the next 10 days?</label>
	  </input>
	</group>
	
	<group>
	  <label>Response by Others</label>
	  <group>
	    <label>What is the response from the local government or panchayats?</label>
	    <group>
	      <label>Food</label>
	      <input bind="r1"><label>For # of people</label></input>
	      <input bind="r2"><label>For # of days</label></input>
	    </group>
	    <group>
	      <label>Water</label>
	      <input bind="r3"><label>For # of people</label></input>
	      <input bind="r4"><label>For # of days</label></input>
	    </group>
	    <group>
	      <label>Treatment</label>
	      <input bind="r5"><label>For # of people</label></input>
	      <input bind="r6"><label>For # of days</label></input>
	    </group>
	    <group>
	      <label>Shelter</label>
	      <input bind="r7"><label>For # of people</label></input>
	      <input bind="r8"><label>For # of days</label></input>
	    </group>
	    <group>
	      <label>Cloth</label>
	      <input bind="r9"><label>For # of people</label></input>
	      <input bind="ra"><label>For # of days</label></input>
	    </group>
	    <group>
	      <label>Fodder</label>
	      <input bind="rb"><label>For # of people</label></input>
	      <input bind="rc"><label>For # of days</label></input>
	    </group>
	  </group>
	  
	  <group>
	    <label>What is the response from other NGOs?</label>
	    <group>
	      <label>Food</label>
	      <input bind="rd"><label>For # of people</label></input>
	      <input bind="re"><label>For # of days</label></input>
	    </group>
	    <group>
	      <label>Water</label>
	      <input bind="rf"><label>For # of people</label></input>
	      <input bind="rg"><label>For # of days</label></input>
	    </group>
	    <group>
	      <label>Treatment</label>
	      <input bind="rh"><label>For # of people</label></input>
	      <input bind="ri"><label>For # of days</label></input>
	    </group>
	    <group>
	      <label>Shelter</label>
	      <input bind="rj"><label>For # of people</label></input>
	      <input bind="rk"><label>For # of days</label></input>
	    </group>
	    <group>
	      <label>Cloth</label>
	      <input bind="rl"><label>For # of people</label></input>
	      <input bind="rm"><label>For # of days</label></input>
	    </group>
	    <group>
	      <label>Fodder</label>
	      <input bind="rn"><label>For # of people</label></input>
	      <input bind="ro"><label>For # of days</label></input>
	    </group>
	  </group>
	</group>
	
	<group>
	  <label>Protection</label>
	    <select bind="p1">
	      <label>Are women, children, or adolescents in danger of any of the following:</label>
	      <item>
	        <label>Sexual abuse / rape</label><value>"y"</value>
	      </item>
	      <item>
	        <label>Abduction / Traficking</label><value>"y"</value>
	      </item>
	      <item>
	        <label>Forced migration</label><value>"y"</value>
	      </item>
	      <item>
	        <label>Forced militia recruitment</label><value>"y"</value>
	      </item>
	      <item>
	        <label>HIV</label><value>"y"</value>
	      </item>
	      <item>
	        <label>Other concerned diseases</label><value>"y"</value>
	      </item>
	      <item>
	        <label>Any other</label><value>"y"</value>
	      </item>
	    </select>  
	    
	    <select1 bind="p2">
          <label>Are the places where people are staying safe from these potential threats?</label>
          <item>
            <label>Yes</label><value>"y"</value>
          </item>
          <item>
            <label>No</label><value>"n"</value>
          </item>
        </select1> 
        
        <input bind="p3"><label>If schools are still functioning, how many children are still attending the school?</label></input>  
    </group>  
    
    <group>
      <label>Additional Questions</label>
      <input bind="x1"><label>How many families have lost access to livelihoods?</label></input>
    </group>
    
  </h:body>
</h:html>   
 